Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out

Ionic Foot Detoxification History Questionnaire Please PRINT

VIEWS: 35 PAGES: 4

Foot bath is a foot care equipment, foot massage and stimulation, can stimulate the function of human potential, to adjust the imbalance between yin and yang, the state body to relieve tension in the body, to the effect of disease prevention and health-care, self care and longevity of the effect.

More Info
									                   Ionic Foot Detoxification History Questionnaire


Please PRINT, ANSWER, and FILL IN ALL the questions/blanks listed in this form.

                                                      Date_______/_______/20_______


Full Name (First, Middle Initial, and Last) _____________________________________

Address ________________________________________________________________

City ___________________________________ State _____________ Zip ___________

Cell Phone ___________________ (H) _______________ (W) ____________________

Email Address ___________________________________________________________

Occupation ___________________________________ How Long? ________________

Height _________ Weight ___________ DOB ______________ Age _______________

Sex _______ Marital Status _______________

Emergency Contact: Name ________________________________________________

Relationship ________________ Phone _______________ Alt Phone _______________

Physician ________________________________________ Phone _________________

Is your physician aware of you receiving an Ionic Foot Bath? _________

Why have you decided to have an Ionic Foot Bath session(s)? Please check all that apply:

              _______ Dr. Suggested or prescription

              _______ Ninth Amendment “right to self treat”

              _______ Other, Please explain: __________________________________

Please state your expectations from receiving an Ionic Foot Bath? __________________

________________________________________________________________________

________________________________________________________________________
                                     Ionic Foot Bath

      CONTRAINDICATIONS: Please check YES or NO for EACH question.

YES    NO
              Do you have a pacemaker?
              Do you have any battery-operated or electrical implant?
              Do you take medication to regulate your heartbeat?
              Are you pregnant?
              Are you breastfeeding?
              When was the date of the last day of your last period?
              Have you ever had an organ transplant?
              Have you ever had an organ removed?
              Have you ever had your colon removed?
              Do you take medications for seizures?
              Do you take medications for psychotic episodes

If you have answered “yes” to any question above, please explain. __________________

________________________________________________________________________

I, _______________________________________________ (print name), certify that I HAVE NOT BEEN
DIAGNOSED WITH ANY CONTRAINDICATIONS FOR AN IONIC FOOT BATH.

Signature and Date ______________________________________________________________________




                                             2
                                Consent and Release

Client Name ____________________________________________________________

Address ________________________________________________________________

City, State, Zip __________________________________________________________



I, _____________________________________________ (client’s printed name), certify that I AM OVER
18 YEARS OF AGE, OR I AM THE FATHER/MOTHER/LEGAL GUARDIAN OF
________________________________ (minor’s printed name). I HAVE FULLY DISCLOSED MY
MEDICAL HISTORY AND HAVE COMPLETELY AND ACCURATELY ANSWERED ALL HEALTH
RELATED QUESTIONS. I WILL ALERT Back To Essentials, LLC OF ANY CHANGES TO MY
HEALTH, MEDICATIONS AND/OR LIFESTYLE AS THEY OCCUR.


I AM AWARE THAT I SHOULD NOT WEAR METAL, USE A COMPUTER OR CELLULAR PHONE
DURING AN IONIC FOOT BATH SESSION.

I UNDERSTAND THAT I SHOULD EAT BEFORE AN IONIC FOOT BATH SESSION IF I HAVE
LOW BLOOD SUGAR.

I UNDERSTAND THAT IF I FEEL ANY DISCOMFORT I AM NOT REMOVE MY FEET FROM THE
IONIC FOOT BATH IMMEDIATELY.

I UNDERSTAND THAT IF I AM ON MEDICATION I SHOULD TAKE THEM AFTER OR FOUR
HOURS PRIOR TO AN IONIC FOOT BATH.

I UNDERSTAND THAT I MUST CONSULT WITH MY MEDICAL DOCTOR IF I HAVE ANY
MEDICAL CONDITIONS, I.E. DIALYSIS, DIABETES, CONGESTIVE HEART FAILURE, ETC.

I AM UNDERGOING TREATMENT(S) ON MY OWN FREE WILL. I UNDERSTAND THAT
ALTHOUGH EVERY PRECAUTION WILL BE TAKEN TO PREVENT COMPLICATIONS, THEY
CAN AND SOMETIMES OCCUR. IF I EXPERIENCE ANY DISCOMFORT, I AM RESPONSIBLE
FOR STOPPING MY SESSION AND IMMEDIATELY NOTIFYING THE THERAPIST. I ACCEPT
FULL RESPONSIBILITY FOR ANY COMPLICATION THAT MAY OCCUR AND HEREBY
ABSOLVE Back To Essentials, LLC AND ITS ASSOCIATES/STAFF/AFFILIATES OF ANY BLAME
FOR ANY COMPLICATIONS RESULTING FROM MY TREATMENTS.

THIS FACILITY DOES NOT CLAIM TO TREAT ANY CONDITION OF DISEASE. I UNDERSTAND
THAT Back To Essentials, LLC PROVIDES THE FACILITY, EQUIPMENT, AND INSTRUCTIONS
FOR THE SELF-ADMINISTERING OF THE IONIC FOOT BATH.               FOR RECEIVING
INSTRUCTIONS AND SESSIONS HERE, I RELEASE AND FOREVER DISCHARGE Back To
Essentials, LLC AND ITS ASSOCIATES/STAFF/AFFILIATES FROM ANY AND ALL
RESPONSIBILITY OR LIABILITY ARISING FROM THESE PROCEDURES. NO GUARANTEES OR
WARRANTIES HAVE BEEN MADE TO ME OR TO THE SUCCESS, VALUE, OR BENEFITS OF
SUCH PROCEDURES.

THIS FORM HAS BEEN FULLY EXPLAINED TO ME AND I CERTIFY THAT I UNDERSTAND
ITS CONTENT. I HAVE READ, UNDERSTAND, AND AGREE WITH THE INFORMATION



                                               3
PRESENTED TO ME. I DECLARE THE INFORMATION I HAVE DISCLOSED HEREIN TO BE
TRUE AND ACCURATE.

Client’s Signature _______________________________________ Date ____/___/20___

Guardian’s Signature ____________________________________Date ____/____/20___
*For Clients under 18 yrs old, the signature and attendance of the parent or guardian is required. *

Who can we thank for referring you? _________________________________________




                                                     4

								
To top